List of current medications and nutritional supplements (include dosages)

I (name)

consent for my child (name)*

to be treated by Dr.*

, a licensed naturopathic physician in the State of Washington.

Description of treatment: Homeopathic medicine uses dilute, natural substances to treat the whole person.
Naturopathic medicine utilizes various natural therapies including herbs, vitamins and minerals, nutritional
recommendations, manipulation, and psychological counseling. Although many scientific studies and years of clinical
experience have shown these procedures to be safe and effective, they are still recognized by some individuals and
groups as “experimental.” I recognize the potential risks and benefits of homeopathic and naturopathic medicine.Potential risks: Adverse reactions to homeopathic medicines, herbs, vitamins, minerals, nutritional recommendations, manipulation, or other prescribed treatments. Potential benefits: Improved health that may lead to prevention or relief of symptoms and elimination of problems. Release: : Fully understanding the above-described information and potential risks, I voluntarily consent to
treatment. Realizing that, as with any medical treatment, no guarantees are possible and none have been
given to me by my doctor or his/her staff regarding any cure or improvement in my condition. I hereby
release Dr. Ullman’s and Dr. Reichenberg-Ullman’s clinic and staff from any and all liability that may arise
as a result of my diagnosis and/or treatment. I understand that any of my questions regarding treatment
will be answered by the doctor, and that I am free to withdraw my consent and to discontinue treatment at
any time. Medical records: I authorize the utilization of clinical or other information contained in my
medical records for research, teaching, or publication in an article or book, so long as my identity, and that
of my child, is not disclosed. Information regarding my case may be shared with other health professionals
or with attorneys, with my permission. Medical records: I authorize the utilization of clinical or other information contained in my child’s medical record for
research, teaching, or publication in an article or book, so long as his/her identity is not disclosed. information regarding
my child’s case may be shared with other health professionals or with attorneys, with my permission. Payment: I have been informed about the doctors’ fees and acknowledge that I am directly responsible for
payment of all charges incurred while I am under the care of Drs. Ullman or Reichenberg-Ullman. I
understand that payments are due at the time of service. I understand that $20 will be charged for any
returned checks. I agree to pay for any costs of collection and/or attorney fees or costs incurred by any
delinquent unpaid balances on my or my child’s account.
Insurance: I will pay all fees directly to The Northwest Center for Homeopathic Medicine (NCHM) at the
time of each visit. I may seek reimbursement from my insurance provider. I am aware that this is a cash
practice, that the doctors do not contract with any insurance providers, and that telephone consultations
may not be covered by insurance.
Insurance: I will pay all fees directly to The Northwest Center for Homeopathic Medicine (NCHM) at the time of each visit and, if appropriate. I may seek reimbursement from my insurance provider. I am aware that this is a cash practice, that the doctors do not contract with any insurance providers, and that telephone consultations may not be covered by insurance.
Cancellations and Missed Appointments: If I must cancel my or my child’s first appointment, I will call or email the office at nchmclinic@gmail.com
no less than 48 hours in advance. In this case, I will receive a full refund minus a $50 administrative fee.
Without sufficient notice, no refund will be possible. If I need to cancel subsequent appointments, except in
the case of true emergency, I will call the office or email nchmclinic@gmail.com no less than 48 hours in
advance to avoid a missed appointment charge. Appointments cancelled between 48 and 24 hours before
my scheduled appointment will be charged half the appointment fee. For appointments cancelled less than
24 hours in advance, or missed, I understand that I will be charged the full appointment fee.
Special Payment: If I have a financial hardship, I may inquire about special arrangements prior to my child’s appointment.
I HAVE READ AND UNDERSTAND THIS AGREEMENT AND AGREE TO ALL OF THE ABOVE PROVISIONS.